Dr. Laurence Sugarman, director of the Center for Applied Psychophysiology and Self-Regulation, operated a primary care pediatric practice in suburban Rochester for 20 years. He became focused on how to integrate preventive mental health care into primary care because all children struggle with anxiety.
At the same time, he was getting more children referred to him who had neurodiversity, with a large number meeting the criteria for autism spectrum disorder (ASD). He noted that many have difficulty controlling their autonomic—so-called “fight or flight”—responses to stress. Sugarman started using biofeedback for what he calls Autonomic Regulation Training (ART). Since young people with ASD often struggle with social skills that make talk therapy difficult, it makes sense to use computer-based strategies, he said. One advantage of ART is that it provides information in real time to participants, who can then decide how to use the data to modify their behavior.
After joining RIT in 2011, Sugarman developed the Minding Anxiety Project (MAP) when RIT President Bill Destler asked him to use his expertise to help the university’s students. The project involved 104 students who self-identified as having anxiety or ASD. Each student completed psychological surveys and selected goals in three areas: academics, social interaction, and self-care (such as hygiene and sleep). Each student then learned how ART works and how to use it.
Students were taught how to control their breathing and sweat gland activity, and change their heart rate and skin blood flow while focusing their attention. “It really helped them,” Sugarman said. At the end of the sessions, all of the students increased their self-concept, lowered their anxiety, and successfully moved toward self-selected goals. Sugarman said the odds were less than 1 in 10,000 that the changes were due to chance.
But what is most curious about the results, Sugarman said, is that there was no clear correlation between the physiological measurements and the students’ reported improvements in anxiety, selfimage, and behavior. Perhaps the students’ experience that they can learn to control their own physiology and anxiety is more important than actual biofeedback changes, Sugarman said.
“It may not be how you make your breathing smoother and long and regular; it may not be that you know how to lower skin conductance. Just knowing that you can [do these things] could be enough,” Sugarman said. MAP has been handed over to Counseling and Psychological Services for them to offer the program to RIT students, faculty, and staff.
Sugarman has taken his ART with kids with ASD a step further to improve autonomic biofeedback training so it’s easier for the child to understand and accomplish. Sugarman points out that, not surprisingly, the neurodiverse are autonomically diverse, meaning they have varied patterns of autonomic control and unpredictable outcomes compared to other children.
For example, the skin conductance of a child with ASD may not increase when a hand claps unexpectedly, and medication may affect a child’s heart rate variability. So commonly used biofeedback signalprocessing software may not be effective.
Sugarman and colleagues developed an algorithm and method called the dynamic feedback set (DyFSS, pronounced diff-iss) to help clinicians quickly and accurately give relevant information to the child. The DyFSS focuses on what the child already is doing best. “Whatever you are doing well, that’s what it feeds back.”
Sugarman gives this example: “If I was playing the violin and you were my teacher, and my intonation and bowing were terrible, and it looked like I was strangling the violin, but the rhythm was really good, you’d say, ‘I really like your rhythm, keep going, keep going with that rhythm,’ with the faith that the positive trends would entrain other abilities.” Sugarman is especially excited about how DyFSS fits in with RIT’s emphasis on access technologies. He views DyFSS as a technical tool “that increases access for the neurodiverse to autonomic regulation training, increasing access to their own abilities to help themselves.”
With RIT students, Sugarman developed a colorful graphical user interface for the DyFSS. A tutorial and quiz, developed with focus groups of kids with ASD, teaches boys and girls with ASD how to develop and master “their super powers” to fight a “stress monster” in various situations to “keep (their) stress control going in the face of adversity.”
The ART protocol was tested with 20 children in a feasibility study; they liked it and their parents reported that ASD behaviors, such as rocking or spinning, improved. The DyFSS is now going through the federal patent approval process. Sugarman and Drs. Dan Mruzek and Tristram Smith at the University of Rochester Medical Center are collaborating to gather resources and grants to take this project into middle schools in Rochester.
Sugarman also is a consultant on an app called “Repetition Rebellion” being developed by Professor Stephen Jacobs of RIT’s Center for Media, Arts, Games, Interaction and Creativity, and Robert Rice, a professor at St. John Fisher College. That project is supported by a grant awarded to the RIT Office of Research. The app tracks repetitive behaviors in autism routines and offers coping practices for the user. Ultimately, with these colleagues, Sugarman plans to develop this work further into a “MindGamers” video game in which “players control their stress while successfully navigating their way past overflowing trash cans, asymmetric wall posters, hallway noise, getting called on (in class) and even bullied through a dingy, Tim Burtonesque school,” Sugarman said.
Four Ph.D.-level students are working as interns performing a year of clinical work in psychiatry in the Rochester community under the oversight of Caroline Easton ’90 (biotechnology/psychology), professor of forensic psychology in the College of Health Science and Technology. The internships are at either Hillside Family of Agencies or Rochester Regional Health.
At Hillside, student Brittany St. Jean uses interactive materials to work with students grades K through 12 to show the effects of illegal drugs on their brain and organs. Students will wear an Oculus Rift, a headset that takes them on a virtual voyage through the human body, showing them the effect of drugs. For example, they see how drugs can stimulate the heart, going from a normal heart beat to a rapid one. “It’s almost like feeling they’re in that environment,” Easton said.
Another tool is called the “virtual roller coaster.” This consists of the child sitting in a gaming chair in front of a large screen. The chair rocks and shakes as the child watches the inside of a brain cell and the negative effects that different drugs have on the brain and behavior. Easton calls it a “creepy, scary ride... We want to show them in an experiential way with these tools that (using drugs) is not fun, it’s dangerous and you can do damage to your organs.”
St. Jean also is looking at whether dual treatment is cost effective. Easton said the cost of integrative care may be as low as $2,500 as opposed to thousands of dollars in criminal justice costs and lost work wages due to time spent in jail.
Also focusing on children is student Cassandra Berbary. She is studying whether playing violent video games results in children modeling that behavior. Berbary works with children with behavior management problems who are in group psychotherapy at Rochester Regional Health. “She’s looking at the correlation between violent video games that they play and how they do in treatment,” Easton said.
Children ages 12 and up often play video games that are not age appropriate and have mature content, and the result may be that they have problems in school with impulsivity and inhibition and other behaviors, Easton said. A part of this study is working with parents to educate them on how to monitor and limit their children’s screen time.
Student Lindsay Chatmon is working with adult clients at Rochester Regional Health who have a chronic mental illness, such as psychosis, major depression, or substance dependency. These clients are participating in either a psycho-educational group or cognitive behavioral group therapy. “She’s trying to make the case that an evidence-based psychotherapy works to target and improve a specific and problematic behavior and whether this healthy change actually works better for these clients in a real-world clinical setting where clients have multiple diagnoses,” Easton said. In fact, “one targeted behavior change can have a snowball effect in the positive direction and it can lead to an overall positive treatment response.”
Two other studies being conducted by the Hillside intern also involve studying adults with substance abuse issues. These are men who also have a history of intimate partner violence. Intern Kaitlin Pughakoff’s work focuses on whether treatment outcomes are better if the men receive therapy for both substance abuse and partner violence, rather than just for one problem. Easton said a previous randomized controlled trial showed better outcomes for the integrated treatment but “we don’t really know how it’s going to work in a real world setting” where clients are treated in larger groups and busy clinicians have a large case load. “Understanding what is effective at decreasing substance use and aggressive behaviors will help us become better at prescribing client-centered behavioral therapy treatment plans,” Easton said.
Easton said offering the clinical internship program to train and educate interns to provide best practices, and obtain Association of Psychology Postdoctoral and Internship Centers (APPIC) membership and American Psychological Association (APA) accreditation is a step toward developing a Ph.D. program in clinical psychology at RIT. Her hope is that the current interns will choose to stay in Monroe County and become clinical leaders in the field of forensic clinical psychology once their internships are complete.